HB284

186943—4

By Representative Patterson

RFD: Insurance

First Read: 21—FEB—l7

ACT #2017-

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HB284

ENROLLED, An Act,

Relating to health benefit plans; to amend Sections

10A-20-6.16, 27—21A—23, and 27—54A—2, Code of Alabama 1975, to

require health benefit plans to cover the treatment of Autism

Spectrum Disorder under certain health insurance plans and

contracts.

BE IT ENACTED BY THE LEGISLATURE OF ALABAMA:

Section 1. Sections 10A-20—6.16, 27'21A—23, and

27-54A—2, Code of Alabama 1975, are amended to read as

follows:

"§lOA—20—6.16.

"(a) No statute of this state applying to insurance

companies shall be applicable to any corporation organized

under this article and amendments thereto or to any contract

made by the corporation; except the corporation shall be

subject to all of the following:

"(1) The provisions regarding annual premium tax to

be paid by insurers on insurance premiums.

"(2) Chapter 55 of Title 27, regarding the

prohibition of unfair discriminatory acts by insurers on the

basis of an applicant's or insured’s abuse status.

"(3) The Medicare Supplement Minimum Standards set

forth in Article 2 of Chapter 19 of Title 27, and Long—Term

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HB284

Care Insurance Policy Minimum Standards set forth in Article 3

of Chapter 19 of Title 27.

"(4) Section 27—1—17, requiring insurers and health

plans to pay health care providers in a timely manner.

"(5) Chapter 56 of Title 27, regarding the Access to

Eye Care Act.

"(6) Rules promulgated by the Commissioner of

Insurance pursuant to Sections 27-7—43 and 27—7—44.

"(7) Chapter 54 of Title 27.

"(8) Chapter 57 of Title 27, requiring coverage to

be offered for the payment of colorectal cancer examinations

for covered persons who are 50 years of age or older, or for

covered persons who are less than 50 years of age and at high

risk for colorectal cancer according to current American

Cancer Society colorectal cancer screening guidelines.

"(9) Chapter 58 of Title 27, requiring that policies

and contracts including coverage for prostate cancer early

detection be offered, together with identification of

associated costs.

"(10) Chapter 59 of Title 27, requiring that

policies and contracts including coverage for chiropractic be

offered, together with identification of associated costs.

“(11) Chapter 54A of Title 27, requiring that

policies and contracts to Ufch coverage for cover certain

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HB284

treatment for Autism Spectrum Disorder under certain

conditions.

"(12) Chapter 12A of Title 27.

"(13) Chapter 2B of Title 27.

"(b) The provisions in subsection (a) that require

specific types of coverage to be offered or provided shall not

apply when the corporation is administering a self—funded

benefit plan or similar plan, fund, or program that it does

not insure.

"§27-21A—23.

"(a) Except as otherwise provided in this chapter,

provisions of the insurance law and provisions of health care

service plan laws shall not be applicable to any health

maintenance organization granted a certificate of authority

under this chapter. This provision shall not apply to an

insurer or health care service plan licensed and regulated

pursuant to the insurance law or the health care service plan

laws of this state except with respect to its health

maintenance organization activities authorized and regulated

pursuant to this chapter.

"(b) Solicitation of enrollees by a health

maintenance organization granted a certificate of authority

shall not be construed to violate any provision of law

relating to solicitation or advertising by health

professionals.

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"(c) Any health maintenance organization authorized

under this chapter shall not be deemed to be practicing

medicine and shall be exempt from the provisions of Section

34—24—310, et seq., relating to the practice of medicine.

"(d) No person participating in the arrangements of

a health maintenance organization other than the actual

provider of health care services or supplies directly to

enrollees and their families shall be liable for negligence,

misfeasance, nonfeasance, or malpractice in connection with

the furnishing of such services and supplies.

“(e) Nothing in this chapter shall be construed in

any way to repeal or conflict with any provision of the

certificate of need law.

"(f) Notwithstanding the provisions of subsection

(a), a health maintenance organization shall be subject to all

of the following:

“(1) Section 27-1—17.

"(2) Chapter 56, regarding the Access to Eye Care

Act.

"(3) Chapter 54, regarding mental illness coverage.

"(4) Chapter 57, requiring coverage to be offered

for the payment of colorectal cancer examinations for covered

persons who are 50 years of age or older, or for covered

persons who are less than 50 years of age and at high risk for

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88284

colorectal cancer according to current American Cancer Society

colorectal cancer screening guidelines.

"(5) Chapter 58, requiring that policies and

contracts including coverage for prostate cancer early

detection be offered, together with identification of

associated costs.

"(6) Chapter 59, requiring that policies and

contracts including coverage for chiropractic be offered,

together with identification of associated costs.

"(7) Rules promulgated by the Commissioner of

Insurance pursuant to Sections 27-7—43 and 27—7—44.

"(8) Chapter 12A.

"(9) Chapter 54A, requiring policies and contracts

to offer-coverage—for pgyg; certain treatment for Autism

Spectrum Disorder under certain conditions.

"(10) Chapter 2B, regarding risk-based capital.

"(11) Chapter 29, regarding insurance holding

company systems.

"§27—54A—2.

"(a) As used in this section, the following words

have the following meanings:

"(1) APPLIED BEHAVIOR ANALYSIS. The design,

implementation, and evaluation of environmental modifications,

using behavioral stimuli and consequences, to produce socially

significant improvement in human behavior, including the use

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HB284

of direct observation, measurement, and functional analysis of

the relationship between environment and behavior.

"(2) AUTISM SPECTRUM DISORDER. Any of the pervasive

developmental disorders or autism spectrum disorders as

defined by the most recent edition of the Diagnostic and

Statistical Manual of Mental Disorders (DSM)7—intluding

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Developmental Diovidci Not Otherwise Specified or the edition

that was in effect at the time of diagnosis.

“(3) BEHAVIORAL HEALTH TREATMENT. Counseling and

treatment programs, including applied behavior analysis that

are both of the following:

"a. Necessary to develop, maintain, or restore, to

the maximum extent practicable, the functioning of an

individual.

"b. Provided or supervised, either in person or by

telemedicine, by a Board Certified Behavior Analyst, licensed

in the State of Alabama, or a psychologist, licensed in the

State of Alabama, so long as the services performed are

commensurate with the psychologist's formal university

training and supervised experience.

"c. Behavioral health treatment does not include

psychological testing, neuropsychology, psychotherapy,

intellectual assessment, cognitive therapy: sex therapy,

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H5284

psychoanalysis, hypotherapy, and long-term counseling as

treatment modalities.

"(4) DIAGNOSIS OF AUTISM SPECTRUM DISORDER.

Medically necessary assessment, evaluations, or tests to

diagnose whether an individual has an autism spectrum

disorder.

“(5) HEALTH BENEFIT PLAN. Any group insurance plan,

policy, or contract for health care services that covers

hospital, medical, or surgical expenses, health maintenance

organizations, preferred provider organizations, medical

service organizations, physician—hospital organizations, or

any other person, firm, corporation, joint venture, or other

similar business entity that pays for, purchases, or furnishes

group health care services to patients, insureds, or

beneficiaries in this state. For the purposes of this section,

a health benefit plan located or domiciled outside of the

State of Alabama is deemed to be subject to this section if

the plan, policy, or contract is issued or delivered in the

State of Alabama. The term includes, but is not limited to,

entities created pursuant to Article 6, Chapter 20, Title 10A.

On and after December 31, 2018, the term includes health

insurance plans administered or offered by the State Employees

Insurance Board and the Public Education Employees Health

Insurance Plan. The term does not include the Alabama Health

Insurance Plan or the Alabama Small Employer Allocation

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HB284

Program provided in Chapter 52 of this title. The term also

includes the terms health insurance policy and health

insurance plan. The term does not include non—grandfathered

plans in the individual and small group markets that were

required to provide essential health benefits under the

Patient Protection and Affordable Care Act as of January 1,

2017, or accident-only, specified disease, individual hospital

indemnity, credit, dental-only, Medicarewsupplement, long-term

care, or disability income insurance, other limited benefit

health insurance policies, coverage issued as a supplemental

to liability insurance, workers' compensation or similar

insurance, or automobile medical—payment insurance.

"(6) PHARMACY CARE. Medications prescribed by a

licensed physician and any health related services deemed

medically necessary to determine the need or effectiveness of

the medications.

"(7) PSYCHIATRIC CARE. Direct or consultative

services provided by a psychiatrist licensed in the State of

Alabama.

"(8) PSYCHOLOGICAL CARE. Direct or consultative

services provided by a psychologist licensed in the State of

Alabama.

“(9) THERAPEUTIC CARE. Services provided by licensed

and certified speech therapists, occupational therapists, or

physical therapists.

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HB284

"(10) TREATMENT FOR AUTISM SPECTRUM DISORDER.

Evidence—based care prescribed or ordered for an individual

diagnosed with an autism spectrum disorder by a licensed

physician or a licensed psychologist who determines the care

to be medically necessary, including, but not limited to, all

of the following:

"a. Behavioral health treatment.

"b. Pharmacy care.

"c. Psychiatric care.

"d. Psychological care.

"e. Therapeutic care.

"(b)(1) A health benefit plan shall offer—coverage

for cover the screening, diagnosis, and treatment of Autism

Spectrum Disorder for an insured “inc years of age or under

nine 18 years of age or under in policies and contracts issued

or delivered in the State of Alabama to employers with at

least 51 employees for at least 50 percent of its working days

during the preceding calendar year. Coverage provided under

this section is limited to treatment that is prescribed by the

insured's treating licensed physician or licensed psychologist

in accordance with a treatment plan.

"(2) To the extent that the screening, diagnosis,

and treatment of autism spectrum disorder are not already

covered by a health insurance policy, a health benefit plan

shall include coverage under this section shall be offered for

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H5284

iupluaiuu in hcaith inaurancc l2 policies and contracts that

are delivered, executed, issued, amended, adjusted, or renewed

in the State of Alabama at the date of the annual renewal—for

coverage on or after October 1, 2017.

"(3) A health benefit plan may not deny or refuse to

issue coverage on, refuse to contract with, or refuse to renew

or refuse to reissue or otherwise terminate or restrict

coverage on an individual solely because the individual is

diagnosed with Autism Spectrum Disorder.

"(c)(1) The Except as provided in subsection (g),

the coverage required pursuant to this section may shall not

be subject to dollar limits, deductibles, or coinsurance

provisions that are less favorable to an insured than the

dollar limits, deductibles, or coinsurance provisions that

apply tO physical iliucaa gcucrally substantially all medical

and surgical benefits under the health insurance plan7flexeept

as otherwise provided for in subsection (e).

"(2) The coverage required pursuant to subsection

(b) may be subject to other general exclusions and limitations

of the health benefit plan, including, but not limited to,

coordination of benefits, participating provider requirements,

restrictions on services provided by family or household

members, utilization review of health care services including

review of medical necessity, case management, and other

managed care provisions.

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H3284

"(d) Coverage under this section shall not be

subject to any limits on the number of visits an individual

may make for treatment of autism spectrum disorder.

"(e) This section may not be construed as limiting

benefits that are otherwise available to an individual under a

health insurance policy.

"(f) Coverage for applied behavior analysis shall

include the services of the personnel who work under the

supervision of the board certified behavior analyst or the

licensed psychologist overseeing the program.

"(g)(l) Except as provided in subdivision (2),

coverage provided under this section for applied behavior

analysis shall be subject to a maximum benefit as follows:

"a. Forty thousand dollars ($40,000) per year for an

insured individual between zero and nine years of age.

“b. Thirty thousand dollars ($30,000) per year for

an insured individual between 10 and 13 years of age.

"c. Twenty thousand dollars ($20,000) per year for

an inSured individual between 14 and 18 years of age.

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"(2) The maximum benefit limit may be exceeded, upon

prior approval by the insurer administering a health benefit

plan, if the provision of applied behavior analysis services

beyond the maximum limit is medically necessary for the

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HB284

insured individual. Payments made by a health benefit plan on

behalf of an individual for any care, treatment, intervention,

service, or item, the provision of which was for the treatment

of a health condition unrelated to the individual's autism

spectrum disorder, shall not be applied toward any maximum

benefit established under this subsection. Any coverage

required under this section, other than the coverage for

applied behavior analysis, shall not be subject to the dollar

limitations described in this subsection.

"+g+ (h) This section may not be construed as

affecting any obligation to provide services to an individual

under an individualized family service plan, an individualized

education program, or an individualized service plan.

"+d+ (iL The treatment plan required pursuant to

subsection (b) shall include all elements necessary for the

health insurance plan to appropriately pay claims. These

elements include, but are not limited to, a diagnosis,

proposed treatment by type, frequency, and duration of

treatment, the anticipated outcomes stated as goals, the

frequency by which the treatment plan will be updated, and the

treating licensed physician's or licensed psychologist's

signature. The health insurance plan may only request an

updated treatment plan ley once every six months from the

treating licensed physician or licensed psychologist to review

medical necessity, unless the health insurance plan and the

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H3284

treating licensed physician or licensed psychologist agree

that a more frequent review is necessary for a particular

patient. Any agreement regarding the right to review a

treatment plan more frequently applies only to a particular

insured being treated for an autism spectrum disorder and does

not apply to all individuals being treated for autism spectrum

disorder by a physician or psychologist. The cost of obtaining

any review or treatment plan shall be borne by the insurer.

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Section 2. In the administration of and provision of

benefits for the Alabama Medicaid program and the Children's

Health Insurance Plan (ALL Kids), the Alabama Medicaid AgenCy

and the Alabama Department of Public Health, on and after

December 31, 2018, shall provide coverage and reimbursement

for the treatment of Autism Spectrum Disorder in the same

manner and same levels as health benefit plans.

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HB284

Section 3. This act shall become effective October

1, 2017.

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H3284

77744 71704756.,

Speaker of the House of Representatives

AIL/4.2.

President and Presiding Officer of the Senate

House of Representatives

I hereby certify that the within Act originated in

and was passed by the House 20—APR—17, as amended.

Jeff Woodard

Clerk

Senate 16—MAY—l7

House lB—MAY—17

APPRoyED Maw! 14, r9017

TIME {0530 0"”:

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Amended and Passed

Concurred in Sen—

ate Amendment

Alabama Secretary Of State

Rct Num....: 2317-33?

Bill Num...: H~284

Recv’d 85/19/17 11:19amKCW

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PATRICKHARRIS,

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